Healthcare Provider Details

I. General information

NPI: 1407570393
Provider Name (Legal Business Name): EDELWEISS INDIVIDUAL AND FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 QUAIL ST STE 206
NEWPORT BEACH CA
92660-2782
US

IV. Provider business mailing address

15615 ALTON PKWY STE 450
IRVINE CA
92618-3308
US

V. Phone/Fax

Practice location:
  • Phone: 949-229-0567
  • Fax:
Mailing address:
  • Phone: 949-229-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SABA MONTAZERIAN
Title or Position: LICENSEDMARRIAGEANDFAMILYTHERAPIST
Credential: LMFT
Phone: 949-229-0567